The importance of the regional cervical lymphatics in oral cavity cancer was noted by Chelius in 1847 who commented, “the neighboring lymphatics become hard and painful” and “once the growth in the mouth has spread to the submaxillary gland, complete removal of the disease is impossible.” In 1847, Warren described the attempted removal of cancer in the neck through an incision from the masseter muscle to the clavicle, although this must have been an unplanned procedure, not based on any anatomical considerations. Kocher in 1880 described the removal of the tongue for cancer through the submaxillary triangle, first removing the lymphatics and submaxillary and sublingual salivary glands. He later proposed that the cervical lymphatics should be removed more widely and described the “Kocher” incision, a Y-shaped incision with the long arm running from the mastoid tip down the anterior border of sternocleidomastoid muscle to the omohyoid muscle, and the short limb running at right angles to the submental region. Later in 1885, Butlin described the removal of cervical lymph nodes for tongue cancer and even discussed the prophylactic removal of these “glands” for tongue cancer.

Solis-Cohen of Philadelphia, America’s first head and neck surgeon, later advocated the removal of cervical lymph nodes during total laryngectomy. However, most of the credit for neck dissection as a curative operation for cervical metastases belongs to George Washington Crile from the Cleveland Clinic. In 1900, he performed different types of neck dissections and subsequently described the classic operation of RND in his seminal article of 1905 published in the Transactions of the Southern Surgical and Gynecological Association. This operation is now considered to be the basic neck dissection and all other procedures are considered to be modifications. George Crile later described his experience with 132 operations of RND in 1906. In this operation, all lymphatic tissues
in the lateral neck from levels I to V are systematically removed in conjunction with the sternocleidomastoid muscle, internal jugular vein, the spinal accessory nerve, and the submandibular salivary gland. The operation was popularized by Hayes Martin from Memorial Sloan-Kettering Cancer Center, who described the stepwise procedure of RND in his classic article in 1951. However, this operation is not without morbidity, as it results in a cosmetic deformity and dysfunction of shoulder movement.

This led to the development of modified/functional neck dissections. Oswaldo Suarez from Argentina was the first to describe functional neck dissection in 1963, now called modified radical neck dissection (MRND). He described the removal of all five lymph node levels in the neck while preserving the spinal accessory nerve, sternocleidomastoid muscle, and internal jugular vein to limit any functional disability in the shoulder. However, his publications were in Spanish and therefore the technique was not popularized until Ettore Bocca, who learned the technique from Suarez, and published it in the English literature in 1967. Selective removal of regional nodal groups based on predictable patterns of lymph node spread were later popularized by Ballantyne from M.D. Anderson Cancer Center. In 1985, Byers from M.D. Anderson Cancer Center used the terms “anterior” and “supraomohyoid” neck dissection to describe the selective neck dissection procedure for cancers of the oral cavity and pharynx. These neck dissections were described for use in patients with clinically negative neck and were based on the philosophy that nodal spread of cancer proceeded in an orderly and predictable fashion. Unfortunately, the terms “modified neck dissection,” “functional neck dissection,” and “selective neck dissection” led to considerable confusion. Therefore, in 1991 the American Academy of Otolaryngology-Head and Neck Surgery published an article classifying neck dissections into comprehensive and selective. This was later updated in 2002. Structures removed and indications for these different types of neck dissection are shown in Table 6.

Comprehensive neck dissections involve the removal of all lymphatic tissues in the lateral neck (levels I to V) and are generally carried out for the clinically positive neck (N+). They can be classified into RND and MRND (Fig. 7), depending on what other structures are excised. RND involves the removal of lymph nodes in levels I to V, and also the sternocleidomastoid muscle, internal jugular vein, spinal accessory nerve, and submandibular salivary gland. MRND is divided into type I, II, or III, depending on the structures that are preserved. Type I MRND involves preservation of one structure, the spinal accessory nerve. Type II involves preservation of two structures: the spinal accessory nerve and the sternocleidomastoid muscle. Type III involves preservation of the spinal accessory nerve, internal jugular vein, and the sternocleidomastoid muscle. Type I MRND is the most commonly employed neck dissection for squamous cell carcinoma of the upper aerodigestive tract with clinically positive neck disease. Type III MRND is most commonly employed for metastatic-differentiated carcinoma of the thyroid.

Selective neck dissection spares all nonlymphatic tissues, including the sternocleidomastoid muscle, internal jugular vein, and spinal accessory nerve. However, it does not
remove all the lymphatic tissues on the involved side of the neck as does a comprehensive neck dissection, but rather uses the selective removal of nodal regions at risk. This is determined by the predictive pattern of metastases based on the location of the primary tumor. It is based on the clinical observation that squamous cell carcinoma of the upper aerodigestive tract metastasizes in a predictable and sequential pattern. Selective neck dissections are therefore generally carried out for the clinically negative neck (N0), where there is at least a 15% to 20% risk of occult metastatic disease. Additional indications may be situations in which surgical access to the primary extends to lymph node groups at risk of metastases. More controversially, it may be used for nodal metastases confined to the first-echelon nodes (usually N1) when the primary is being treated by surgery. However, it is important to point out that the neck requires postoperative radiation therapy in this setting, as reported by Byers, Pellitteri et al., Spiro et al., and Traynor et al.

Common selective neck dissections are shown in Fig. 8. These include the supraomohyoid neck dissection (SOHND), in which lymph nodes in levels I to III and the submandibular salivary gland are removed (Fig. 8A); the extended SOHND, in which lymph nodes in levels I to IV and the submandibular gland are removed (Fig. 8B); the anterolateral neck dissection (LND), in which lymph nodes in levels II to IV are removed (Fig. 8C); posterolateral neck dissection (PLND), in which lymph nodes in levels II to V and also the suboccipital and retroauricular lymph nodes are removed (Fig. 8D); and central or anterior compartment neck dissection, in which lymph nodes at level VI in the prelaryngeal, pretracheal, and paratracheal regions are removed (Fig. 8E).